Left Ventricular Apical Thrombus Many Months After Pericardial Biopsy

A 39-year-old woman presented with recurrent episodes of acute pericarditis over a four year period. Repeated transthoracic echocardiograms showed normal left ventricular dimensions and wall motion (Figure 1A).

During the last episode, open pericardial biopsy was performed but did not reveal evidence of a specific aetiology. Fifteen months later, the patient was referred because of atypical chest pain, most likely of musculo-skeletal origin. However, the ECG at that time showed Q waves and negative T waves in leads V1 to V4. Transthoracic echocardiography now revealed a left ventricular apical aneurysm (Figure 1B), with a thrombus evident after contrast administration (Figure 1C). Coronary angiography showed smooth coronary arteries with the exception of a totally occluded mid-to-distal left anterior descending artery (LAD, Figure 2). Review of the operation report on the pericardial biopsy procedure revealed the annotation of “accidental perforation of the right ventricle resulting in heavy bleeding”, which was treated by surgical suture. Retrospectively, the LAD rather than the right ventricle must have been injured, and attempts to achieve haemostasis must have resulted in occlusion of the mid-to-distal LAD with subsequent apical infarction with aneurysm and thrombus formation. As evident from the angiogram (Figure 2) the patient’s heart had a somewhat unusual rotation. The more anterior position of the left ventricle and adhesions between the pericardium and epicardium following several episodes of pericarditis may have made the LAD more prone to this unusual complication.

Funding / potential competing interests

No financial support and no other potential conflict of interest relevant to this article were reported.